Have you been advised by a physician to reduce your alcohol consumption?

Yes

No

Do you smoke or chew tobacco?

Yes

No

Have you used any illegal narcotics?

Yes

No

Is your health impaired in any way?

Yes

No

Are you taking medication?

Yes

No

Do you have high blood pressure?

Yes

No

Do you have asthma, emphysema or respiratory problems?

Yes

No

Do you have cancer or other tumors?

Yes

No

Do you have diabetes?

Yes

No

Do you have AIDS, HIV?

Yes

No

Are you pregnant?

Yes

No

Have you ever been declined life,health or disability insurance?

Yes

No

Are you a U.S. citizen?

Yes

No

Remarks:

Coverage Information

Annual Gross salary including tips, fees, and commissions

How long have you been employed at your present occupation?

What percentage of your income do you want your disability policy to cover?

50%

60%

65%

70%

How long do you want the elimination period to be (length of time you must be disabled before you start to receive benefits)?

How long do you want the benefit period to be (maximum length of time you will receive benefits after you have been classified as being disabled and satisfied the elimination period)?

Are you self-employed?

Yes

No

What is your occupation?

Please describe your duties at your current job:

Please explain your reason for purchasing disability insurance:

Do you currently have disability insurance?

Yes

No

If yes, how much?

Questions or Comments

Best Time To Contact You

Please let us know the best time to call and discuss your quote.

Morning

Afternoon

Evening

Anytime

Or Specify Other:

Before submitting, type in required validation security code: 71e4el

* Required Fields

Christopher Smith is an agent with WNC Health Insurance / The Asheville Blue Cross and Blue Shield of North Carolina® Store located in Asheville, North Carolina. Christopher Smith is an ACA / Obamacare enrollment specialist and also specializes in group health insurance, employee benefits, disability insurance, life insurance, long-term care insurance, individual health insurance and critical illness insurance for business owners and individuals. Christopher Smith is an authorized producer licensed to sell and promote products from Blue Cross and Blue Shield of North Carolina®. The content contained in this site is maintained by Christopher Smith. Blue Cross and Blue Shield of North Carolina® is an independent licensee of the Blue Cross and Blue Shield Association®. Registered mark of the Blue Cross and Blue Shield Association (SM) Service mark of the Blue Cross and Blue Shield Association. This web site may contain concepts that have legal, accounting and tax implications. It is not intended to provide legal, accounting or tax advice. You may wish to consult a competent attorney, tax adviser, or accountant. http://www.christopher-smith-insurance.com. Christopher Smith is affiliated with Josh Williams Enterprises, Inc dba WNC Health Insurance / The Asheville Blue Cross and Blue Shield of North Carolina® Store. http://www.wnchealthinsurance.com. Our Privacy Statement: http://christopher-smith-insurance.com/file/b30a101c2a534314cafda28be737bb38